Consultation skills development in general practice: findings from a qualitative study of newly recruited and more experienced clinical pharmacists during the COVID-19 pandemic.

The new structured medication review (SMR) service was introduced into the National Health Service in England during the COVID-19 pandemic, following a major expansion of clinical pharmacists within new formations known as primary care networks (PCNs). The aim of the SMR is to tackle problematic polypharmacy through comprehensive, personalised medication reviews involving shared decision-making. Investigation of clinical pharmacists' perceptions of training needs and skills acquisition issues for person-centred consultation practice will help better understand their readiness for these new roles. A longitudinal interview and observational study in general practice. A longitudinal study of 10 newly recruited clinical pharmacists interviewed three times, plus a single interview with 10 pharmacists recruited earlier and already established in general practice, across 20 newly forming PCNs in England. Observation of a compulsory 2-day history taking and consultation skills workshop. A modified framework method supported a constructionist thematic analysis. Remote working during the pandemic limited opportunities for patient-facing contact. Pharmacists new to their role in general practice were predominantly concerned with improving clinical knowledge and competence. Most said they already practiced person-centred care, using this terminology to describe transactional medicines-focused practice. Pharmacists rarely received direct feedback on consultation practice to calibrate perceptions of their own competence in person-centred communication, including shared decision-making skills. Training thus provided knowledge delivery with limited opportunities for actual skills acquisition. Pharmacists had difficulty translating abstract consultation principles into specific consultation practices. SMRs were introduced when the dedicated workforce was largely new and being trained. Addressing problematic polypharmacy requires structural and organisational interventions to enhance the communication skills of clinical pharmacists (and other health professionals), and their use in practice. The development of person-centred consultation skills requires much more substantial support than has so far been provided for clinical pharmacists. [Abstract copyright: © Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Alcohol, the overlooked drug: clinical pharmacist perspectives on addressing alcohol in primary care.

Attempts to routinely embed brief interventions in health systems have long been challenging, with healthcare professionals concerned about role adequacy, legitimacy, and support. This is the first study to explore clinical pharmacists' experiences of discussing alcohol with patients in their new role in UK primary care, in developing a novel approach to brief intervention. It investigates their confidence with the subject of alcohol in routine practice and explores views on a new approach, integrating alcohol into the medication review as another drug directly linked to the patient's health conditions and medicines, rather than a separated 'healthy living' issue. The study forms part of wider efforts to repurpose and reimagine the potential application of brief interventions and to rework their contents. Longitudinal qualitative study of 10 recruits to the new clinical pharmacist role in English primary care, involving three semi-structured interviews over approximately 16 months, supplemented by 10 one-off interviews with pharmacists already established in general practice. When raised at all, enquiring about alcohol in medication reviews was described in terms of calculating dose and level of consumption, leading to crude advice to reduce drinking. The idea was that those who appeared dependent should be referred to specialist services, though few such referrals were recalled. Pharmacists acknowledged that they were not currently considering alcohol as a drug in their practice and were interested in learning more about this concept and the approach it entailed, particularly in relation to polypharmacy. Some recognised a linked need to enhance consultation skills. Alcohol complicates routine clinical care and adversely impacts patient outcomes, even for those drinking at seemingly unremarkable levels. Changing clinical practice on alcohol requires engaging with, and supportively challenging, routine practices and entrenched ideas of different kinds. Framing alcohol as a drug may help shift the focus from patients with alcohol problems to problems caused for patients by alcohol. This is less stigmatising and provides role legitimacy for pharmacists to address alcohol clinically in medication reviews, thus providing one element in the formation of a new prevention paradigm. This approach invites further innovations tailored to other healthcare professional roles. [Abstract copyright: © 2023. The Author(s).

Quarterly Economic Commentary, January 1984

The international economic recovery became quite firmly established in 1983, with substantial growth recorded in North America, Japan, and to a lesser extent the UK. Against this background, the decline in the Irish economy was halted, and substantial gains were made in several aspects. The overall growth rate was miniscule at about Y2 per cent, but there was a massive improvement in the balance of payments, a significant increase in industrial output, a marked reduction in the rate of inflation, some slowing down in the growth of unemployment, and a small reduction in tpe budget deficit as a proportion of Gross National Product. It seems likely that 1984 will see a continuation of most of these trends. Gross National Product should increase by about 2 per cent in volume, the current account balance of payments deficit should fall to around £50 million, and the increase in consumer prices should be held to about 8Y2 per cent. However, the indications are that progress will continue to be very slow in relation to the two major problems of unemployment and the public finances. Employment could well stabilise at about its present level and even increase slightly later in the year, but this would still leave unemployment increasing at a rate of some 18,000 per year because of the growth in the labour force. On the assumption of a passive budget, in which both income tax bands and specific rates of excise duty are indexed in line with inflation, it seems probable that there would be very little change in the size of the nominal current budget deficit, although it would be reduced as a proportion of Gross National Product. While neither of these outcomes can be regarded as at all satisfactory, there is little room for manouevre in budgetary strategy. Too determined an attempt to reduce the deficit could impair the expected recovery and increase the rise in unemployment, while trying to reduce unemployment by allowing the deficit to rise would be a short-term expedient which would intensify both problems in the longer term. Probably the most hopeful strategy would be to aim for a slightly lower deficit, while hoping that this and other current forecasts of the rate of economic recovery prove unduly cautious

Molecular dark matter in galaxies

Clouds containing molecular dark matter in quantities relevant for star formation may exist in minihaloes of the type of cold dark matter included in many cosmological simulations or in the regions of some galaxies extending far beyond their currently known boundaries. We have systematically explored parameter space to identify conditions under which plane-parallel clouds contain sufficient column densities of molecular dark matter that they could be reservoirs for future star formation. Such clouds would be undetected or at least appear by current observational criteria to be uninteresting from the perspective of star formation. We use a time-dependent PDR code to produce theoretical models of the chemistry and emission arising in clouds for our chosen region of parameter space. We then select a subset of model clouds with levels of emission that are low enough to be undetectable or at least overlooked by current surveys. The existence of significant column densities of cold molecular dark matter requires that the background radiation field be several or more orders of magnitude weaker than that in the solar neighbourhood. Lower turbulent velocities and cosmic ray induced ionization rates than typically associated with molecular material within a kpc of the Sun are also required for the molecular matter to be dark. We find that there is a large region within the parameter space that results in clouds that might contain a significant mass of molecular gas whilst remaining effectively undetectable or at least not particularly noticeable in surveys. We note briefly conditions under which molecular dark matter may contain a dynamically interesting mass.Comment: 9 pages, 2 figures, accepted for publication in A&A; additional concluding paragraph added at proof stag

Integration of a clinical pharmacist workforce into newly forming primary care networks: a qualitatively driven, complex systems analysis

Objective The introduction of a new clinical pharmacist workforce via Primary Care Networks (PCNs) is a recent national policy development in the National Health Service in England. This study elicits the perspectives of people with responsibility for local implementation of this national policy package. Attention to local delivery is necessary to understand the contextual factors shaping the integration of the new clinical pharmacy workforce, and thus can be expected to influence future role development. Design A qualitative, interview study Setting and participants PCN Clinical Directors and senior pharmacists across 17 PCNs in England (n=28) Analysis Interviews were transcribed, coded and organised using the framework method. Thematic analysis and complex systems modelling were then undertaken iteratively to develop the themes. Results Findings were organised into two overarching themes: (1) local organisational innovations of a national policy under conditions of uncertainty; and (2) local multiprofessional decision-making on clinical pharmacy workforce integration and initial task assignment. Although a phased implementation of the PCN package was planned, the findings suggest that processes of PCN formation and clinical pharmacist workforce integration were closely intertwined, with underpinning decisions taking place under conditions of considerable uncertainty and workforce pressures. Conclusions National policy decisions that required General Practitioners to form PCNs at the same time as they integrated a new workforce risked undermining the potential of both PCNs and the new workforce. PCNs require time and support to fully form and integrate clinical pharmacists if successful role development is to occur. Efforts to incentivise delivery of PCN pharmacy services in future must be responsive to local capacity

Export Tourism: Input-Output Multipliers in Ireland - A reply. Quarterly Economic Commentary Special Article, November 1983

In the course of an article on "Export Tourism Input-Output Multipliers for Ireland" in the ESRI Quarterly Economic Commentary of May 1982 Desmond A. G. Norton derived some estimates in respect of tourism activity and drew comparisons between his estimates and those of others including Byrne and Palmer. The following comments are set out in order to indicate sources of these differences

Water exchange at a hydrated platinum electrode is rare and collective

We use molecular dynamics simulations to study the exchange kinetics of water molecules at a model metal electrode surface -- exchange between water molecules in the bulk liquid and water molecules bound to the metal. This process is a rare event, with a mean residence time of a bound water of about 40 ns for the model we consider. With analysis borrowed from the techniques of rare-event sampling, we show how this exchange or desorption is controlled by (1) reorganization of the hydrogen bond network within the adlayer of bound water molecules, and by (2) interfacial density fluctuations of the bulk liquid adjacent to the adlayer. We define collective coordinates that describe the desorption mechanism. Spatial and temporal correlations associated with a single event extend over nanometers and tens of picoseconds.Comment: 10 pages, 9 figure

Intermediate range chemical ordering of cations in simple molten alkali halides

The presence of first sharp diffraction peaks in the partial structure factors is investigated in computer simulations of molten mixtures of alkali halides. An intermediate range ordering appears for the Li+ ions only, which is associated with clustering of this species and is not reflected in the arrangement of other ions. This ordering is surprising in view of the simplicity of the interionic interactions in alkali halides. The clustering reflects an incomplete mixing of the various species on a local length scale, which can be demonstrated by studying the complementary sub-space of cations in the corresponding pure alkali halides by means of a void analysis.Comment: 5 pages, 5 figure

The Evolution of the Rate of Unemployment in Ireland 1962-1983. Quarterly Economic Commentary Special Article, May 1984

For decades an objective of policy in Ireland has been to lower the rate of unemployment - indeed to achieve full employment. Yet instead of falling, the rate of unemployment has increased rather dramatically to record levels. Many possible explanations for this state of affairs have been advanced. One view looks at the demand for labour and points to the slow growth in the world economy and to a failure of real wages to respond sufficiently to the energy price shocks of the 1970s. Job losses in the 1970s and 1980s have been the key source of unemployment according to this view. An alternative interpretation notes the sharp reversal of net emigration during the last decade and a half and attributes the growth in unemployment to a corresponding surge in labour supply at home. According to a third, less plausible perspective, the increase in unemployment is largely a function of an increase in the propensity of those not genuinely seeking work to apply for (increasingly generous) unemployment assistance or benefits or in an increase in the time spent searching for suitable jobs. Probably each of the three factors has played a part in governing the evolution of the rate of unemployment in Ireland over the past two decades, though their relative importance is the subject of much dispute--. In other larger countries, unemployment has also increased sharply. The role of migration there is obviously small, and the explanation is usually shared between the other two factors. For Ireland, however, migration may be a dominant element in the long run providing the link with unemployment conditions in other countries

The Naas Motorway Bypass - A Cost Benefit Analysis. Quarterly Economic Commentary Special Article, January 1984

The paper examines the Naas Motorway Bypass which cost £16m at 1983 prices. Twelve thousand vehicles a day using the bypass save over 10 minutes between 8 am and 8 pm and 6 minutes at other times. Five thousand vehicles a day using the present route through Naas also benefit by saving 4 minutes due to reduced congestion in the town. In addition to time savings, the bypass reduces accidents and fuel costs. Ninety-one per cent of the benefits accrue in time savings. The internal rate of return on the project is estimated at 20.51 per cent, assuming 2 per cent annual traffic and income growth. The sensitivity tests of the results show that even with zero growth in incomes and traffic for twenty years, a high proportion of leisure time savings with zero value and no increase in the value of fuel savings the project would have an internal rate of return which meets the test discount rate used by the Department of Finance. The environmental aspects of the bypass are positive in terms of noise and smoke and lead pollution reduction. The impact on farm severence and natural amenities on the motorway route has been mitigated by several design features of the bypass